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ER I SEWER UTUTY&PPUCATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: t (L IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT # BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX []MULTI -FAMILY-# OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑ NO ❑ YES, FROM TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER (check all that L'9 SyE SEWER REPAIR I El El WATER SERVICE INSTALLATION ;7sl—DE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY I ❑ NEW SIDE SEWER INSTALLATION ❑ INSTALL BACKWATER VALVE outside the building) 1 ❑ SIDE SEWER CAP -OFF ❑ SIDE SEWER RECONNECTION MULTIPLE DOMESTIC WATER SERVICES REQUEST ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM, SERVICE / METER USE: ❑ SFR ❑ MULTI -FAMILY -# OF UNITS: ❑ COMMERCIAL WATER SERVICE TYPE / SIZE: (circle desired size) ❑ DOMESTIC: 314", 1", 2", OTHER: ❑ IRRIGATION: 3/4", 1", 2", OTHER: ❑ FIRE: 1", 2", 4", 6", 8", OTHER: ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: CONTACT INFORMATION. t OWNER NAME: \ TENANT NAME (If Commercial): OWNER MAILING ADDRESS: STREET M v 'p— a CITY STATE ZIP , OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: Q \, v�L u' CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): CITY OF EVERETT BUSINESS LIC. #(REQUIRED): PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT., The undersigned applicant agrees to comply with all provisions of the tverett municipal Looe i tue 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have the right at any time, without notice, to shut off or turn on the water supply forrepairs, construction, and nonpayment of charges or for any other reasonable cause. I am the owner, or I am authorized by the owner of this property to perform the work for which application is made, and I comply with the State Contractors Law 18.27 RC796, I —A I A ' FEE F ERMIT # Owner/Authorized Agent Signature 'ti Date (Revised 10/12/2015)